Robinson, Raymond NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
ar Name First Middle Last Sex
Raymond F. Robinson Male
__.`: Date of Death Age If Veteran of U.S. Armed Forces,
.. November 15,2016 85 War or Dates Korean
Place of Death Hospital, Institutiofirondack Tri-County Health Care
City, Town or Village Johnsburg Street Address Center
• Manner of Death — Undetermined Pending
Natural Cause Accident Homicide Suicide
lit Circumstances Investigation
w` Medical Certifier Name Title
ck James Hindson Dr.
: Address
Main St.,Warrensburg,NY 12885
Death Certificate Filed District Number Register Number
n City, Town or Village Johnsburg 5655
❑Burial Date Cemetery or Crematory
November 16,2016 Pine View Crematory
❑Entombment Address
❑X Cremation Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
y
O Date Point of
u) Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Renterment
Date Cemetery Address
<= Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
., Address
3809 Main Street,Warrensburg,NY 12885
,n Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
U1
Permission is hereby granted to dispose of the human r ains described ove as ind d.
n: Date Issued 11-16-16 Registrar of Vital Statistics 2b s
ignature)
District Number 5655 Place Johnsburg,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition /I J17I/o, Place of Disposition )23 n.e-- L1 Q,I.J Cr. . -...jo r '>,,-- .-N
2 (address)
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CO
IX (section) (lot number) (grave number)
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p Name of Sexton or Person in Charge of Premises U a fs7 L! /jo,..., h,, . ��
Z (please print)
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Signature 14., Title C.,t.--,.14o,--
(over)
DOH-1555 (02/2004)